Download Immunodeficiencies

Immunodeficiencies
Martin Liška
Immunodeficiency
= a disorder of immune system which manifests by
impaired ability to carry out basic immunological
functions, primarily defence against infection or
immunological surveillance
Immunodeficies
• Humoral – nonspecific immune system – complement system
specific immune system – immunoglobulins (B cells)
• Cellular – nonspecific – phagocytes
specific – T cells
• Primary – hereditary, symptoms manifest mostly in early stages
• Secondary – acquired, symptoms manifest mostly in any stages of
life
variable etiology (metabolic diseases, malignancies,
immunosupressants, infections, stress etc.)
Typical age for immunodeficiency
manifestation
• Early infancy - severe combined primary immunodeficiencies
• 6 months – 2 years – severe hereditary antibody deficiencies
• 3 - 5 years – transitory or selective antibody deficiencies,
secondary immunodeficiencies
• 15 – 20 years – hormonal instability, thymus involution, lifestyle
changes, some typical infections (EBV), first symptoms
of CVID
• Middleage – excessive workload, stress, CVID, autoimmune disease,
malignancies
• Advanced/old age – rather symptoms of secondary
immunodeficiencies
Immunodeficiency – the main clinical
features
• Antibody d. - recurrent microbial infections (capsulated bacteria)
respiratory - pneumonia, sinusitis, otitis
GIT – diarrhea
• Complement system d. – microbial infections (pyogenic), sepsis
immunocomplex diseases (SLE)
swellings in HAE – C1-inhibitor deficiency
• T cells (+ B cells) d. - bacterial, fungal, viral infections
GIT – diarrhea
respiratory – pneumonia, sinusitis
• Phagocytes d.- abscesses, recurrent pyogenic infections of skin,
granulomatous inflammation
Primary immunodeficiencies
Primary immunodeficiencies
Defects of phagocytes
Defects of complement system
Predominantly antibody deficiencies
Combined T cell and B cell immunodeficiencies
Diseases of immune dysregulation
Well-defined syndromes with immunodeficiency
European registry of primary
immunodeficiencies from 2003 (prevalence
1,52/100000)
Disorder
Frequency (%)
Antibody deficiencies
66,3
T cell deficiencies + combined
17,6
Defects of phagocytes
7,4
Complement system defects
6,2
Other primary immunodeficiencies
2,5
Various types of primary
immunodeficiency in Czech Republic
(2003)
Primary immunodeficiency
X-linked agamaglobulinaemia
CVID
HyperIgM syndrome
Selective IgA-deficiency
Selective deficiency of IgG subclasses
SCID
DiGeorge syndrome
Wiskott-Aldrich syndrome
Hereditary angioedema
C2 deficiencey
C4 deficiency
LAD I
CGD
HyperIgE syndrome
Chronic mucocutaneous candidiasis
X-linked lymphoproliferative syndrome
Frequency (%)
3,9
19,6
0,8
51,2
2,4
1,5
4,6
0,5
10,6
0,4
0,5
0,2
1,8
1,2
0,4
0,4
I. Defects of phagocytes
1/ Quantitative defects of phagocytes
a/ neutropenia, granulocytopenia
• severe congenital neutropenia (Kostmann sy.)
• cyclic neutropenia
• reticular dysgenesis
I. Defects of phagocytes
2/ Quantitative defects of phagocytes
-
impaired ability of phagocytes to phagocyte or kill ingested microbes
a/ Chronic Granulomatous Disease (CGD)
• X-linked (60%), event.AR
• defect of NADPH oxidase system → impaired ability to produce toxic
oxygen metabolites (e.g.H2O2) → decreased ability to kill microbes
(especially producing catalase: Staph.aureus or Pseudomonas aeruginosa)
Symptoms: onset at early age
formation of granulomas and abscesses in skin and organs
Dg: respiratory burst test (FCM)
genetic tests
Th: ATB prophylaxis
in more severe cases BMT or gene therapy
I. Defects of phagocytes
b/ Myeloperoxidase deficiency
• susceptibility to infections caused by Staph.aureus or Candida
albicans
c/ Chédiak-Higashi syndrome
• recurrent severe pyogenic infections (streptococci,
staphylococcci)
• neutrophils contain giant lysosomes (disorder of their content
release → impaired killing of microbes)
Dg: neutrophils with abnormal chemotaxis and killing
Th: ATB, ev.BMT
I. Defects of phagocytes
d/ adhesion deficiency (LAD syndrome)
• defects of neutrophil adhesion molecules expression
• LAD I – defect of integrins expression
• LAD II – defect of selectins expression
Clin.sympt.: recurrent skin and mucous infections, impaired
healing of umbilical cord scar, formation of abscesses
(especially in periproctal region) with poor production of pus
Dg: proof of decreased CR3 expression
Th: ATB, transfusion of donor granulocytes
only treatment is BMT
II. Defects of complement system
a/ C1, C2, C3, C4 deficiency
• Increased development of systemic immunocomplex diseases (SLE-like),
susceptibility to pyogenic infections
b/ C6, C7, C8, C9 deficiency
• Susceptibility to pyogenic infections, in C9 deficiency meningococcal
infections
c/ MBL deficiency
• Mannan Binding Lectin deficiency (lectin pathway of complement system
activation), increased frequency of common infections
II. Defects of complement system
d/ Hereditary angioedema (HAE)
• absence or functional defect of C1 inhibitor
• C1-inhibitor = regulation of complement system, kinin and
hemocoagulation cascade → in case of C1-INH deficiency:
dysregulation of bradykinin metabolism → swellings
Symptoms: recurrent swellings of skin, mucous membranes of
larynx, gut (mimicking intestinal obstruction)
onset mostly in adolescence
triggering factor most frequently injury, surgery
(e.g.dental), intercurrent infection
• Laryngeal swelling could be life-threatening without rescue therapy
II. Defects of complement system
d/ Hereditary angioedema (HAE)
Dg: C1-inhibitor concentration assessment
C4 concentration assessment
functional test of C1-inhibitor
genetics
Th: preventive – androgens (Danazol), antifibrinolytics
(tranexamic acid), C1-inhibitor concentrate
rescue – administration of C1 inhibitor concentrate (Berinert),
selective bradykinin-receptor inhibitor (icatibant –
Firazyr), recombinant C1-inhibitor (Ruconest)
• Angioedema can be secondary too
III. Predominantly antibody
immunodeficiencies
X-linked (Bruton’s) agammaglobulinemia (XLA)
•
Mutation of Bruton’s tyrosinkinase gene (Btk)(Xq21.3-22) → block of maturation of
pre-B cell into B cell → severely decreased Ig levels and B cell numbers
•
Most common X-linked form, but rarely forms affecting girls
Symptoms: onset between 6th month and 2nd year of age: recurrent pneumonias,
pyogenic otitis, sinusitis with complications
increased risk of pulmonary fibrosis
Dg: IgG, IgA, IgM levels ˂ 2* SD of age mean
absence of isohemaggulutinins and/or poor seroconversion to vaccination
B cell numbers markedly decreased or absent
genetic tests
Th: life-long IVIG substitution
III. Predominantly antibody
immunodeficiencies
Common Variable Immunodeficiency (CVID)
•
•
Heterogenous group of diseases manifested by markedly decreased serum IgG a
IgA levels (˃2* SD of age mean)
Similar to XLA, but symptoms onset usually at 2nd – 3rd decade of life
Symptoms: recurrent infections of respiratory tract, esp.pneumonias (Pneumococci,
Haemophilus, Branhamella, Mycoplasma)
complications: tumors or autoimmune diseases, e.g.hemolytic anemia,
fibrosis, endocrinopathies, lymphoproliferations, bronchiectasies
Dg: IgG+A markedly decreased
poor seroconversion to vaccination
numbers of B cells decreased or slightly increased
genetic test (mutations ICOS, BAFF, CD19, CD20 etc.)
Th: life-long IVIG or SCIG substitution
dispensarisation
III. Predominantly antibody
immunodeficiencies
Transient hypogammaglobulinemia of infancy (THI)
• Delayed onset of antibody production → decreased levels of Ig (esp.IgG),
get normal until cca 3 years of age
• More frequent infections, esp.of respiratory tract
• B cell numbers normal
Th: symptomatic, event.transiently IVIG
III. Predominantly antibody
immunodeficiencies
Selective IgA deficiency (SIAD)
• Impaired function of B cells
• The most common X the mildest PID
Symptoms: recurrent respiratory infections X very often without any
symptoms
Dg: IgA ˂ 0,07 g/l at age of ≥ 4 years, levels of IgG and IgM normal
Th: no treatment
patients with SIAD are not allowed to be vaccinated with live oral
vaccines; in case of blood transfusion, the should get autotransfusion or
properly washed erythrocytes
III. Predominantly antibody
immunodeficiencies
IgG subclasses deficiency, specific Ig deficiency
• Impaired production of some IgG subclass or specific IgG (e.g. against
Pneumococci or tetan)
• Symptoms manifest usually during childhood, most commonly respiratory
infections caused by capsulated bacteria (H. influenzae, Pneumococci)
Th: symptomatic
in some cases, IVIG substitution necessary
III. Predominantly antibody
immunodeficiencies
HyperIgM syndrome (HIGM)
•
•
Hereditary disorder of isotype switching
X-linked form is more frequent (defect of CD40L expression on surface of activated T cells or
defect of its function), less frequent is AR form (non-functional CD40)
Symptoms: severe neutropenia
opportunistic infections
symptomatology similar to the other antibody deficiencies (XLA)
Dg: IgM level normal or increased, levels of other Igs are low
FCM assessment of CD40L expression on T cells
genetic tests
Th: IVIG substitution
prophylaxis with TRI/COT
BMT
IV. Combined T cell and B cell deficiencies
a/ Severe Combined Immunodeficiency (SCID)
•
•
One of the most severe PIDs; without BMT, patients die during the first years of life
Defect of T cell function which can be accompanied with B cell and NK cell disorder
 The most common is X-linked form (T-B+NK-)
-
The mutation affects so called common gamma chain (protein shared by receptors of
various cytokines (IL-2, IL-4, IL-7, IL-9,IL-15, IL-21)) → severe defect of lymphocyte
development and differentiation → severe decrease or absence of T cells and NK cells
Number of B cells normal X insufficient help from T cells → insufficient production of
antibodies
 JAK-3 deficiency
-
Similar features like X-linked form (defect of signal transmission through common
gamma chain)
IV. Combined T cell and B cell deficiencies
a/ Severe Combined Immunodeficiency (SCID)
 IL-7 R or CD45 deficiency (T-B+NK+ form)
 Adenosine deaminase (ADA) or purine nucleoside phosphorylase (PNP) deficiency
-
AR heredity
These defects lead to purine metabolites cumulation → inhibition lymphocyte
proliferation (ADA) or toxic effect to lymphocytes (PNP) → absence of T and B cells
(T-B- form) – this form of SCID develops also on the basis of other mutations
(e.g.RAG1 or RAG2 recombinase deficiency, MHC gp.II expression defect)
IV. Combined T cell and B cell deficiencies
a/ Severe Combined Immunodeficiency (SCID)

Omenn syndrome
-
Severe PID belonging to SCID group
Mutation of RAG recombinases →impaired VDJ recombinations → proliferation of one or more
clones of autoreactive T cells → unlike in classical SCID, Omenn syndrome need not to display T
lymphopenia (numbers of T cells can be increased) X number of B cells and Ig are very low
Symptoms: lymphadenopathy, hepatomegaly, generalized erythroderma with allopecia, symptoms
typical for SCID (pneumonia, chronic diarrhea, failure to thrive)
Dg: evidence of T cells clonality
genetic tests

Reticular dysgenesis syndrome
-
The most severe form of SCID
Mutation of adenylate kinase 2 gene (AK2) → increased apoptosis of myeloid and lymphoid
precursors
T-B- form of SCID
-
IV. Combined T and B cell deficiencies
a/ Severe Combined Immunodeficiency (SCID)
•
Clinical symptoms of SCID
-
Onset in infancy
Commonly severe infections of respiratory tract (pneumonia)
Failure to thrive, exanthemas similar to eczema, chronic diarrhea
Absence of tonsils and adenoids
Infections caused by bacterias, viruses or fungi – typically pneumocystic pneumonia,
candidiasis, CMV infections, infections caused by BCG (BCGitis)
•
Treatment of SCID
-
The only successful and ultimate treatment is BMT performed as soon as possible
Substitution of Ig
IV. Combined T cell and B cell deficiencies
b/ diGeorge syndrome
-
deletion of long arm of chromosome 22 (22q11.2) → defective development of 3rd
and 4th branchial pouch (complete, partial)
rare cases of diGeorge syndrome without 22q11.2 deletion
AD heredity
typically defect of development (absence) of thymus and/or parathyroid glands,
severe congenital heart disease is characteristic, facial dysmorfia, mental retardation
Symptoms: usually symptoms of VCC predominates (typically Fallot’s tetralogy)
sometimes hypocalcemic spasms due to hypoparathyroidism
immunodeficiency (recurrent respiratory infections), usually not so severe like
in SCID
Dg.: typical symptoms
genetic tests
Th: cardiac surgery, symptomatic treatment of hypoparathyroidism and
immunodeficiency, dispensarisation
Facial dysmorfia in diGeorge
syndrome
Combined T cell and B cell deficiencies
DiGeorge syndrome
X-SCID
MHC gp.II deficiency
CD4+
Reticular dysgenesis
PNP deficiency
Pluripotent
stem cell
Lymphoid
progenitor
ADA deficiency
Pre-T cell
Thymus
CD8+
V. Immunodeficiency with immune
dysregulation
a/ X-linked lymphoproliferative syndrome (XLP)
• Abnormal immune response to EBV infection which leads to
uncontroled lymphoproliferation
• Disorder of gene localized on X chromosome - mutation of gene
coding protein associated with signal activating molecule of
lymphocytes SLAM (SAP) or inhibitor of apoptosis (XIAP)
• Development of uncontroled lymphoproliferation and NK cell
disorder
• EBV infection with fulminant or fatal course leading to liver failure
→ surviving patients are at risk of B cell lymphoma development,
hypogammaglobulinemia similar to CVID or aplastic anemia
• Without BMT performed before EBV infection development, XLP is
fatal sooner or later
V. Immunodeficiency with immune
dysregulation
b/ Chronic mucocutaneous candidiasis
• Primary immunodeficiency manifesting by recurrent infections of
mucous membranes and skin caused by Candida in consequence of T
cell disorder
• Sometimes candidiasis combined with alopecia and
polyendocrinopathy (APECED = Autoimmune PolyEndocrinpathyCandidiasis-Ectodermal Dystrophy)
• Mutation of genes STAT1, IL17RA etc.
• Treated with antimycotics, ev.by substitution of lacking hormones
VI. Well-defined syndromes with
immunodeficiency
a/ HyperIgE syndrome (HIES, Job’s syndrome)
•
Eczema + combined immunodeficiency manifesting by recurrent abscesses (cold abscesses)
+ recurrent sinopulmonary infections
•
More common AD form caused by mutation of STAT3 gene (Signal Transducer and Activator
of Transcription 3), less common AR form caused by mutation of DOCK8 gene (Dedicator Of
CytoKinesis 8)
Symptoms: onset frequently in infancy
recurrent staphylococcal abscesses of skin, lungs, joints or internal organs
recurrent sinopulmonary infections, pneumatocele
severe atopic eczema
in AD form: skeletal disorders (facial asymmetry, prominent forehead, broad nasal
bridge, spontaneous bone fractures, osteopenia), delayed dental erruption
Typical facial features in HIES
VI. Well-defined syndromes with
immunodeficiency
a/ HyperIgE syndrome (HIES, Job’s syndrome)
Symptoms: in AR form, recurrent viral infections (herpetic), increased
frequency of autoimmune or allergic diseases, skeletal
disorders often absent
Dg: clinical features
enormously increased level of serum IgE (˃ 2000 IU/ml)
genetic tests
Th: prophylaxis with anti-staphylococcal ATB
dermatological therapy of eczema
surgical treatment of abscesses
VI. Well-defined syndromes with
immunodeficiency
b/ Wiskott-Aldrich syndrome (WAS)
• X-linked recessive disease
• Decreased number of small platelets (microthrombocytopenia), eczema
and immunodeficiency
• Mutation of WASp gene → decreased production of WASp protein
(exprimed on hematopoietic cells, provides dynamic changes of
cytoskeleton which are necessary for function of immune cells)
Symptoms: combined immunodeficiency: decreased Ig levels (↓IgM; ↑IgA
and IgE) + defects of T cell function → recurrent otitis and
sinusitis, autoimmune diseases
thrombocytopenia → increased bleeding
VI. Well-defined syndromes with
immunodeficiency
b/ Wiskott-Aldrich syndrome (WAS)
Dg: clinical symptoms
proof of decreased expression of WASp on leukocytes
genetic tests
Th: symptomatic treatment
in case of matched donor BMT
studies of gene therapy
VI. Well-defined syndromes with
immunodeficiency
c/ Ataxia-teleangiectasia
• AR disease – mutation of gene ATR (11q22-q23) →
defect of ATM proteinkinase → defective mechanisms
of DNA reparation → increased sensitivity to ionizing
radiation → ↑susceptibility to develop malignancies
Symptoms: ataxia + teleangiectasia
↓IgA+E → recurrent sinopulmonary infections
hypoplasia of thymus a lymph nodes
Th: symptomatic
Immunoglobulin replacement therapy
• Immunoglobulin concentrates are made from human plasma pooled from
thousands of donors
• Donors are tested for infectious diseases (HIV, hepatitis), inactivating
procedures to minimize the risk of transmitting infection
• Ig concentrates contain only IgG, content of IgA is minimal
• Preparates for i.v. (Gammagard, Octagam) or s.c. administration (Subcuvia,
Gammanorm)
Indications for Ig replacement therapy
• Primary antibody deficiencies (IVIG) – life-long in XLA or CVID, transitory in
combined immunodeficiencies (SCID)
• IgG subclasses or specific Ig deficiency is sometimes also indication
• Secondary antibody deficiencies – typically B cell leukemia, lymphoms
Dosage of Ig concentrates
• Agammaglobulinemia – i.v. imunoglobulins 400-600 mg/kg/month
•
Regular administration in day-care centres every 3 or 4 weeks
• Last years, „home therapy“ is frequently used - administration of
subcutaneous Ig by infusion pump (cca every 5 to 7 days, more
comfortable for patient, less adverse effects)
Administration of subcutaneous Ig by
infusion pump
Adverse effects of the treatment
• Allergic reactions, anaphylaxis
• In less severe reactions (shivers, headache), slowing down the infusion is
usually sufficient
• Sometimes, premedication with intravenous corticosteroids is necessary
• Change of preparate (lower content of IgA)
Secondary
immunodeficiencies
Secondary immunodeficiencies
• Acute and chronic viral infections – infectious mononucleosis, influenza
• Metabolic disorders – diabetes mellitus, uremia
• Autoimmune diseases – autoantibodies against immunocompetent cells
(neutrophils, lymphocytes); autoimmune phenomena also after
administration of certain drugs (e.g. oxacilin, quinidine)
• Allergic diseases
• Chronic GIT diseases
• Malignant diseases (leukemia)
• Hypersplenism/asplenia
• Burn, postoperative status, injuries
• Severe nutritional disorders
• Chronic infections
• Ionizing radiation
• Drug induced immunodeficiencies (chemotherapy)
• Immunosupression
• Chronic stress
• Chronic exposure to harmful chemical substances
Secondary immunodeficiencies
• Splenectomy – deficiency in generation of antibodies against encapsulated
microorganisms (Pneumococci, Neisseria)
• A loss of immunoglobulins – nephrotic syndrome
- lymphangiectasies
• Lymphomas, myelomas, CLL
Acquired ImmunoDeficiency Syndrome
(A.I.D.S.)
• Caused by Retrovirus HIV 1 or HIV 2
• Current incidence 37 mil.people, predominantly in central Africa,
2mil. of new infections per year, 1.2 mil. deaths per year
• CZ:10/14 - HIV+ 2330, AIDS 423, deaths 310
• Virus has a tropism for cells bearing CD4 (CD4+ T helper cells); also
affects macrophages and CNS cells
• Virus uses for entering into cells CD4 receptor and some chemokine
molecules (CCR5 and CXCR4)
• Viral genome transcribes into human DNA by using reverse
transcriptase and infected cell provides viral replication
• Transmission: sexual contact
body fluids (blood and blood products)
mother-to-child (prenatal, delivery, breastfeeding)
Acquired ImmunoDeficiency Syndrome
(A.I.D.S.)
Phases:
 acute - 3 to 6 weeks after primoinfection
- flu-like symptoms or asymptomatic
 asymptomatic - months or years
- viral replication, loss of Th cells
 symptomatic - decrease of Th cells
- fevers, weight loss, anorexia
- infections (oropharyngeal candidiasis), autoimmune
disorders, malignancy, allergy
 AIDS - systemic breakdown,
- opportunistic infections: pneumocystis pneumonia,
Cryptococcus, Mycobacteria, Toxoplasmosis etc.
- neoplasms (Kaposi’s sarcoma, Burkitt’s lymphoma)
Acquired ImmunoDeficiency Syndrome
(A.I.D.S.)
Diagnosis:
-
Serology - specific antibodies, 4 to 12 weeks after primoinfection
Measurement of antigen p24 – before seroconversion
Viral RNA measurement – before seroconversion, PCR testing
Th cells counts
Therapy:
- HAART (Highly Active Antiretroviral Therapy) – combination of
nucleoside (Zidovudine) and non-nucleoside (Nevirapin) reverse
transcriptase inhibitors and protease inhibitors (Lopinavir)
Acquired ImmunoDeficiency Syndrome
(A.I.D.S.)
Therapy:
- Prophylaxis with antibiotics and antimycotics
- TBC prevention (isoniazid)
- Ig replacement